- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.57 / $620.29 / $836.55
| Professional | | $606.57 | $620.29 | $836.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.92 / $736.39 / $1,191.89
| Professional | | $625.92 | $736.39 | $1,191.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $871.13 / $1,258.25
| Professional | | $350.00 | $871.13 | $1,258.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.03 / $867.02 / $1,177.83
| Professional | | $623.03 | $867.02 | $1,177.83 |